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New Road Surgery: 01923 604884 Out Of Hours: 111Patient Access

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Home
About Us
Health
Patient Information
Carers Support
PPG
Contact Us

Baby Registration Pack

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Baby Registration Pack

Claire Chesworth

Kevin Barrett

Clare Jenkins

Kunal Patel

Practice Manager: Catherine Garibaldi
The Surgery

166 New Road

Croxley Green

Rickmansworth, WD3 3HD

www.newroadsurgery.info

Tel: 01923 604884
Family Doctor Services Registration (GMS1)
Patient's details*

MrMrsMissMs
Surname*
Date of birth*

DayMonthYear
Date
First names*
NHS No.*
Gender*

MaleFemale
Previous surname/s
Town and country*
Home Address*

Street Address

Street Address Line 2

CityCounty

Post Code
Telephone number*
Please help us trace your previous medical records by providing the following information.
Address

Street Address

Street Address Line 2

CityCounty

Post Code
Name of GP practice while at that address*
Address of previous GP practice*

Street Address

Street Address Line 2

CityCounty

Postcode
If you are from abroad, your first UK address where you registered with a GP

Street Address

Street Address Line 2

CityCounty

Post Code
If previously resident in UK, date of leaving

DayMonthYear
Date
Date you first came

DayMonthYear
Date
Were you ever registered with an Armed Forces GP
Please indicate if you have served in the UK Armed forces and/or been registered with a Ministry of Defence GP in the UK or overseas

RegularFamily Member (Spouse, Civil Partner, Service Child)VeteranFamily Member (Spouse, Civil Partner, Service Child)
Address before enlisting

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Service or Personnel number:
Enlistment date:

DayMonthYear
Date
Discharge date:

DayMonthYear
Date
Footnote: These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services.
If you need your doctor to dispense medicines and appliances

I live more than 1.6km in a straight line from the nearest chemistI would have serious difficulty in getting them from a chemist
Signature of patient

Clear
Signature on behalf of patient

Clear
Date of signature

DayMonthYear
Date
What is your ethnic group?
White:

BritishIrishIrish TravellerTravellerGypsy/RomanyPolishOther White (please specify)
Mixed:

White and Black CarribeanWhite and Black AfricanWhite and AsianOther Mixed (please specify)
Asian or Asian British:

IndianPakistaniBangladeshiOther Asian (please specify)
Black or Black British:

CarribeanAfricanSomaliNigerianOther Black (please specify)
Other ethnic group:

ChineseFilipinoOther ethnic group (please specify)
Not stated:

Please select here if you wouldn't like to state your ethnicity

Short Form for Babies (under 12 months)
Today's Date

DayMonthYear
Baby's Details
Title
Surname*
First Name (s)*
Date of Birth

DayMonthYear
Date
NHS Number
Name(s) of parent(s), guardian(s) or carer(s) and their relationship to the baby:
Name
Relationship
Please confirm that you hold parental responsibility for this child

YesNo
Home Telephone Number
Mobile Telephone Number
If you are over 16 please put your own mobile phone number NOT parent/guardian's number
Text Messaging Service

We will send you text messages to remind you of appointments, enable you to cancel your appointmentsand receive updates regarding initiatives e.g. stop smoking.

Please indicate if you wish to “opt in” to our text messaging service by ticking below
I consent to be contacted by SMS text messaging on this mobile number
Should be Empty:

Contact Info

Telephone:
01923604884

Address:
New Road Surgery,
166 New Rd,
Croxley Green,
Rickmansworth,
WD3 3HD

Find Us

Opening Hours

Monday 8am to 8pm
Tuesday 8am to 6:30pm
Wednesday 8am to 6:30pm
Thursday 8am to 8:00pm
Friday 8am to 6:30pm
Sat - 7:50 - 10am (Pre booked appointments only)

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New Road Surgery | Accessibility Statement | GP Earnings